435202509-4-24-2025-26-AS-CKAI-DG2QM9-20250424121709

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202509
Report Date: 04/24/2025
Date Signed: 04/24/2025 12:17:20 PM

Document Has Been Signed on 04/24/2025 12:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	VILA MONTE		FACILITY NUMBER:	435202509
ADMINISTRATOR/ DIRECTOR:	NICHOLAS INNEH		FACILITY TYPE:	740
ADDRESS:	17090 PEAK AVENUE		TELEPHONE:	(408) 500-2693
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 28		CENSUS: 25	DATE:	04/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:05 AM
MET WITH:	Nicholas Inneh		TIME VISIT/ INSPECTION COMPLETED:	12:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required 1 year annual inspection. LPA met with Administrator (ADM), Nicholas Inneh. During visit, LPA toured the facility with ADM to include the resident bedrooms, bathroom, shower room, kitchen, hallways, dining room, and exterior. All fire exit routes were free and clear of obstruction. Medications, disinfectants, sharp objects observed locked. Staff present are fingerprint cleared and associated to the facility. The facility has an activity calendar, laundry schedule, shower schedule, and personal rights form posted in the hallway. Facility temperature maintained at 69 degrees F. Resident bedrooms contains adequate lighting, beds, linens, dressers/closet space, and a night stand. Facility has at least 7 days worth of non-perishables and 2 days worth of perishable foods. The kitchen is equipped with 2 refrigerators which were maintained at 30 degrees F and the 2 freezer temperatures maintained at 0 degrees F. Items inside the refrigerator observed covered. LPA recommended to clean, de-clutter, and organize the kitchen and pantry. LPA did not observe any rodents or insects in the kitchen during visit. Hot water temperature in the bathroom maintained at 111.4 degrees F. Facility has an operable carbon monoxide and smoke detector. Fire extinguishers last serviced on 04/19/2024. Facility has a sprinkler system. Emergency disaster plans posted next to the exit doors. The facility has emergency flood lights in each hallway in case of a power outage. The last emergency drill was completed on 01/15/2025. Facility has a first aid kit located in the medication room. See LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: VILA MONTE	FACILITY NUMBER: 435202509
	VISIT DATE: 04/24/2025

NARRATIVE

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LPA reviewed 3 resident files. 3 residents records observed complete to include an admission agreement, updated physician's report, TB result, updated appraisal/needs and services plan, consent form, safeguard of personal properties/valuables, personal rights, centrally stored medication record, and cash resources. 2 out of 3 resident's has cash resources which was inspected with the ADM and observed complete.

LPA observed there are no start dates on the resident's CSMR or on the medication bubble pack/bottle. LPA observed the facility is not maintaining the resident's medication administrator record (MAR) as the last input was dated on 04/19/2025 and some medications were not listed on the MAR. ADM was advised.

During the medication inspection, LPA observed 1 resident was not provided their daily routine medication from 04/08/25 - 04/23/25 because the resident was out of medication. ADM states they had called the pharmacy and doctor the 2-3 days before the resident's medication ran out. ADM called the doctor during visit and found the resident's medication was already refilled and delivered to the facility on 04/23/25.

LPA reviewed 5 staff files. 5 staff records observed complete to include health screening, TB result, personnel record, and fingerprint clearance. 2 out of 5 staff has an active 1st aid certification. 5 staff are provided annual training in compliance with Title 22 regulations.

ADM is informed of a late/outstanding balance of the facility's annual licensing fee that was due on 04/13/2025.

ADM was informed about the Department's Technical Support Program (TSP) as a resource for medication administration. ADM is familiar with the TSP website on cdss.ca.gov.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/28/2025 11:43 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/02/2025 10:22 AM

Created By: Christine Kabariti On 04/24/2025 at 11:35 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: VILA MONTE	FACILITY NUMBER: 435202509
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(4)

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	THIS DEFICIENCY WAS INADVERTENTLY AMENDED. Based on observation, interview, and record review, the licensee did not comply with the section cited above wherein the licensee did not ensure 1 resident was provided their routine medication from 04/08/25 - 04/23/25 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2025
	Plan of Correction
1 2 3 4	Licensee will submit a written plan regarding how the facility will ensure resident's medications refills are followed-up with timely before a resident's medication runs out. Licensee will submit the POC to LPA Kabariti via email by POC due date.

Type B

Section Cited

CCR

87506(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	THIS DEFICIENCY WAS INADVERTENTLY AMENDED. Based on observation, interview, and record review, the licensee did not comply with the section cited above wherein the licensee did not ensure the centrally stored medication records contained a start date which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2025
	Plan of Correction
1 2 3 4	Licensee states they will implement start dates on the record and medication. Licensee will submit a written plan to LPA Kabariti via email by POC due date

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:

	Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

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